While MSF cannot work directly in Syria, it has collected testimonies from wounded patients treated outside the country and from doctors inside Syria.  The testimonies, collected from several people from various parts of the country, point to a crackdown on the provision of urgent medical care for people wounded in the ongoing violence in Syria.  

“In Syria today, wounded patients and doctors are pursued and risk torture and arrest at the hands of the security services,” said Marie-Pierre Allié, MSF president. “Medicine is being used as a weapon of persecution.”

Most of the wounded do not go to public hospitals for fear of being tortured or arrested. When a wounded person is admitted to a hospital, a false name is sometimes used to hide his or her identity.  Doctors sometimes provide a false diagnosis to help patients elude security forces, who search for patients with wounds consistent with those sustained in protests and demonstrations. People have suffered grievous injuries, including from shrapnel and from bullets that apparently explode on impact.  The testimonies recount instances of people shot by snipers.

“It is critical that the Syrian authorities reestablish the neutrality of healthcare facilities,” said Marie-Pierre Allié. “Hospitals must be protected areas, where wounded patients are treated without discrimination and are safe from abuse and torture, and where medical workers do not risk their lives by choosing to comply with their professional code of ethics.”

The injured are largely treated in clandestine treatment facilities by doctors trying to fulfill their commitment and duty to provide medical assistance. Improvised health clinics have been established in apartments, on farms, and elsewhere. Simple rooms outfitted as makeshift operating theatres, known as “mobile hospitals,” are used for surgical procedures.  Hygiene and sterilisation conditions are rudimentary and anaesthesia is in short supply.  Furthermore, the mere possession of drugs and basic medical materials, such as gauze, is considered a crime.

“The security services attack and destroy the mobile hospitals,” said a doctor who requested anonymity. “They enter houses looking for drugs and medical supplies.”

Security is the key concern for doctors working in the parallel underground networks. In the prevailing climate of terror, treatment must be provided rapidly since medical workers and patients must constantly change location to avoid detection. 

“We are constantly being pursued by the security forces,” said another physician. “Many doctors who treated wounded patients in their private hospitals have been arrested and tortured.”

It is extremely difficult for the clandestine health workers to treat major trauma cases and provide post-operative care. Additionally, they cannot obtain blood from the central blood bank, which is controlled by Syria’s Ministry of Defence — the only blood supplier in the country.

Only a few wounded patients have managed to find refuge in neighbouring countries, where they can receive proper—albeit delayed—medical care.   

“I was wounded in the thigh and the soldiers caught me,” recounted a patient treated by MSF. “They beat me on the head and on my wound, but I managed to get away with help from people in the neighbourhood. In the end, I found someone who could treat me — a nurse, not a doctor. He didn’t even have anaesthetic.”

Under the current circumstances, MSF’s assistance to Syrians requiring medical care is limited.  For months, MSF has been seeking official authorisation to aid the wounded in Syria, so far without success. The organisation is treating patients outside Syria and is supporting doctors’ networks inside the country, through the provision of medicine, medical supplies, and surgical and transfusion kits.   

Source: member // Medecins Sans Frontieres – UK 

A pointed example of the gap between perception and performance is Maimonides Medical Center in Brooklyn, NY. Although it gets low rankings from patients, who think it’s dirty and noisy, the article notes:

“Medicare data released today shows that Maimonides is one of 13 of more than 4,700 hospitals nationwide with below-average death rates for all three conditions: 11.2% for heart attacks, compared with a national average of 15.9%; 7.3% for heart failure, compared with 11.3%; and 6.8% for pneumonia, compared with 11.9%.”

By contrast, the USA Today writers also identified more than 120 hospitals with outcomes significantly below the national average for MI, HF, and pneumonia that nevertheless received high praise from patients.

[WSJ]- The vast majority of U.S. hospitals have restricted the use of life-saving chemotherapy drugs and other critical-care medications in the past six months to cope with unprecedented shortages, according to a survey released Tuesday.

More than 80% of hospitals surveyed by the American Hospital Association reported they had to delay treatment, and nearly 70% said patients received less effective substitute drugs.

Three out of four hospitals reported rationing or restricting the use of drugs in short supply. For some drugs, such as a leukemia drug called cytarabine, there are no effective substitutes.

The survey of 820 hospitals was released by the AHA on Capitol Hill as part of push for legislative action. A separate survey commissioned by the American Society of Health-System Pharmacists estimated additional labor costs for hospitals to deal with the shortages at $216 million a year. Pharmacists and technicians spend about 17 hours a week managing drug shortages.
Most of the drugs in question are generic and not highly profitable, and are now made by only one or two companies. Teva Pharmaceutical Industries Ltd. and Hospira Inc. are two of the bigger producers of generic drugs.

The shortages are growing more severe, in part, because of industry consolidation and manufacturing problems in the past year. When one company runs into a manufacturing problem with a product or decides to quit making a drug, competing companies can’t quickly fill the void. In April, Teva reopened a California plant that it had shut down voluntarily for about a year, in part to retool to meet Food and Drug Administration manufacturing guidelines.

The FDA reported a record 178 drug shortages in 2010. Although the agency doesn’t have figures for 2011, it said the shortages “have continued at a rapid pace.”

Most of the shortages involve older, generic drugs administered by injection or intravenously. They include chemotherapy drugs to treat cancer, antibiotics to treat infections and nutritional drugs for patients who can’t eat. There are also continuing shortages of drugs used in emergency rooms and intensive-care units.

More than 90% of hospitals in the hospital-association survey reported shortages of surgery or anesthesia drugs and emergency-care drugs, and two-thirds reported shortages of chemotherapy drugs. Almost half of the hospitals reported coping with 21 or more shortages in the past six months.

The pharmacists’ survey showed the biggest shortage in 2010 involved the drug succinylcholine, used in procedures to insert a tube into patients’ airways to help them breathe.

The product is made by Hospira and Sandoz, a unit of Novartis AG. Production at Hospira was slowed last year when the company couldn’t get enough active pharmaceutical ingredients and Sandoz couldn’t immediately fill the gap. Hospira said full production has resumed. Sandoz didn’t immediately respond to a request for comment.

Bills introduced in the House and Senate would require companies to notify the FDA when they have a problem that could result in a shortage. Current law requires companies to report to the FDA in cases when they are the only supplier of a drug and they plan to quit making it.

The House bill, sponsored by Reps. Diana DeGette (D., Colo.) and Tom Rooney (R., Fla.) would subject companies to fines of up to $10,000 a day, with a cap of $1.8 million, for failure to comply with reporting requirements.

The measure would also allow the FDA to post letters online from companies informing the FDA of potential or actual shortages, to give hospital pharmacists a better gauge of how long a particular shortage might last. Hospira and the FDA support the bill.

Sen. Amy Klobuchar (D., Minn.), co-sponsor of a similar Senate bill, said the legislation is meant as an early warning system. While some companies do notify the FDA about potential problems like shortages of ingredients used to make drugs, Ms. Klobuchar described the current system as “haphazard.”

The FDA has said 38 shortages were prevented in 2010 when companies voluntarily gave the agency early notification of a problem with a drug. In some cases, the advanced warning gave the FDA time to work with competing manufacturers to ramp up production.

The deal puts Highmark into the hospital business in a big way, and floats a life preserver to a hospital system that has been losing money each quarter, including a $22 million operating loss in the quarter ending March 31.

Executives from both Highmark and West Penn Allegheny called the partnership “a historic transaction for Pittsburgh,” one that will put WPAHS on sure financial footing, and will help maintain a viable option to the region’s largest hospital system, the University of Pittsburgh Medical Center, which controls more than half of the hospital beds in the region and many of its physicians, too.

“They are well-capitalized, and we’re not,” said David L. McClenahan, WPAHS board chairman, speaking of Highmark. “That’s putting it mildly.” In the decade since the collapse of the Allegheny Health Education and Research Foundation, whose bankruptcy eventually bore the West Penn Allegheny Health System, WPAHS has been persistently starved for capital, he said.

WPAHS wanted to remain independent, that was no longer an option, financially, he said. Had the deal with Highmark not materialized, WPAHS was preparing a budget that would have included the autumn closure of West Penn Hospital.

While the short-term goal of this partnership is to preserve a “fragile” Pittsburgh hospital system, the long term goal, said Highmark CEO and President Kenneth Melani, is the creation of a new model of health care, one that is outcomes based, with an integrated delivery and financing system.

“Health care services are becoming less affordable,” he said. “It’s important to have choice. It’s important to have a second system.”

He also said that while the Highmark-WPAHS partnership is the primary product of this deal, the two institutions will also work to strengthen relationships with other regional hospitals and physicians’ practices.

Also announced today, Christopher Olivia, president and CEO of West Penn Allegheny Health System, will step down from that position, effective immediately. He will take on a consulting position at Highmark, he said at the press conference this morning.

With Dr. Olivia’s departure, Dianne Dismukes has been named interim president and CEO. Ms. Dismukes last month was named executive vice president for hospital operations at WPAHS, replacing Dawn Gideon.

Following the signing of a tentative “term sheet,” Highmark “is immediately providing a $50 million grant to the WPAHS” to strengthen its West Penn and Forbes Regional hospitals “while assuring the continued delivery of quality medical services by the entire system.”

Highmark is making “a total financial commitment of up to $475 million over four years, including $75 million to fund scholarships for students attending medical schools affiliated with WPAHS, and to support other health professional education programs,” according to the morning’s press release.

Earlier this month, Dr. Olivia announced that WPAHS would open a regional campus of Temple University’s School of Medicine.

Throughout the morning, Highmark and West Penn officials took some verbal jabs at UPMC, noting more than once, for example, that WPAHS is the only local hospital system currently offering live transplants, as a result of having UPMC suspended those operations last month after a patient received a kidney from a donor with hepatitis C.

Officials from Highmark and WPAHS organizations (which are both non-profits) also tried to draw a distinction between WPAHS and UPMC, saying UPMC is not behaving like a not-for-profit community asset in the way that it tries to “maximize revenue” and put WPAHS out of business.

Highmark and UPMC relations have frayed in recent months as negotiations over a new reimbursement contract are at an impasse, with Highmark claiming that UPMC wants too much money, and UPMC saying that it cannot, and will not, sign a deal with an insurer that is now partner with a UPMC competitor.

The partnership’s framework will be fleshed out over the coming two months, and the organizations hope it will be approved within six months. Some aspects of the deal may need state approval.

“Ultimately, we expect the Department will be one of the regulators that has a role in reviewing and approving the proposed arrangement between Highmark and West Penn,” said Pennsylvania Insurance Department Commissioner Michael F. Consedine in a statement.

“However, no formal agreement has yet been signed and no filing has been submitted to the Department for its review.”

Cathy Stoddart, staff nurse at Allegheny General Hospital and an SEIU member and union leader representing the system’s 2,000-plus nurses, said the deal may prove beneficial for staff.

“I’m actually pretty excited,” she said. “To have our system have money is something that hasn’t happened in 11 years.”

Read more: http://www.post-gazette.com/pg/11179/1156765-100.stm#ixzz1QsjoQ4wP

Neither Bishop’s sister, a longtime advocate for her (who works in the justice system) whom a court years earlier declined to make Bishop’s legal guardian, nor Bishop’s daughter were informed of her condition during her extended stay in New Hampshire’s state hospital — nor were they told when she was discharged. Instead, a fantasy relationship that Bishop had for years in her head, with no contact with the man, was her plan for support, even marriage, upon leaving the hospital.

The story of Linda Bishop’s multiple psychiatric hospitalizations, her misdemeanor (non-violent) offenses and time in jail, her abandonment of her teenage daughter, her assertion that she was not mentally ill and her refusal to follow any treatment plan, the lack of evidence that she could care for herself, and the self-imposed distance from her family was all too familiar to me and my colleagues working in public mental health, even if the details of her situation may vary in some ways from others. Recognized experts (and longtime colleagues) Drs. Tom Gutheil and Paul Appelbaum in 1979 (!) aptly called this type of tragedy “rotting with their rights on.”

Our laws stipulate that Bishop had to consent to provide information to her family, which she did not. Privacy violations would have been the consequence of the hospital contacting her family during the hospital stay or at the time of discharge. Bishop’s “right” to live where (and how) she wanted derives from legal rulings that stipulate a person’s right to live in what is called “the least restrictive setting.”

The letter of the law had been met. And the patient died.

Arguments have been made on the polar extremes of this dilemma. On one side are patient rights advocates who are stalwart about privacy and self-determination. In fact, legal organizations are present to defend these rights in state hospitals throughout this country. Considerable legal rulings now protect individuals from involuntary hospitalization and involuntary treatment by requiring court action to achieve both, with the exception of emergency situations. On the other side are advocates calling for increasing commitments of people with serious mental illness, including outpatient commitment (and requiring that those committed take psychiatric medications for their disorders), and longer hospital stays.

Never having been one for extremes, except maybe when it came to my playing sports, I believe there are viable middle grounds — even if difficult to reach.

For example, nine years ago the first Mental Health Court was established in New York City, under the remarkable (and continued) leadership of Judge Matthew D’Emic. There are now seven such courts in NYC, about 25 in New York State and approximately 200 around the country (not counting drug and domestic violence courts). A mental health court accepts referrals from other courts where there appears to be a mental illness complicating the crime. Court mental health specialists evaluate the person for a mental illness, and if present, the defendant can plead guilty (in New York State) and be “sentenced” to court ordered treatment under the supervision of the judge; other states may divert the person from jail, have charges held in abeyance pending completion of the treatment program, or other procedures according to local statute. This form of supervised treatment is typically for a year (the maximum sentence for a misdemeanor). More recently, there are mental health courts working with felons where the court ordered treatment can go on for years.

For example, outpatient commitment already exists in almost every state (this has been the case in New York State for over 10 years, instituted after Kendra Webdale was pushed before an oncoming subway train by a man with a psychotic illness). The law, Kendra’s Law, has been renewed twice, each time for five years. We don’t need more outpatient commitment (though some state statutes warrant updating); we need more outpatient treatment that works.

Which brings me to my main point: outpatient mental health services in this country don’t work very well, despite the dedicated people who work for them. The result is that early intervention and the provision of comprehensive, continuous, proven (evidence-based) treatments is being delivered to less than 20 percent (!) of people who need it. That means more than four out of five people are not getting what they need for their illness and recovery. Lack of good care coupled with lack of housing are the principal drivers for the clinical deterioration, chronic homelessness, use of jails and prisons as institutions to contain people with mental disorders, and suicidal and violent behaviors among those who are mentally ill. This country is in need of a mental health overhaul, as candidly portrayed in the President’s New Freedom Commission on Mental Health (December 2002; disclosure: the Commission’s chair was Michael Hogan, Ph.D., now Mental Health Commissioner for the state of New York, and my boss).

Mental health has treatments that work. It has mission-oriented professionals and provider organizations. But it lacks organization, accountability and financing that pays for what is accomplished rather than what is simply done. Sounds familiar? That’s because mental health care is part of health care, where the same issues apply in capital letters.

As this country grinds its way to a more responsive, and hopefully affordable, health care system, what can be done now? For one, mental health clinics can be held to specific standards of care and their licenses made dependent on delivering those standards. Measurement-based care can be introduced (and required) where improvement from mental illness is tracked just like we track blood pressure, blood sugar and lipids. Incremental financing reforms can better support evidence-based practices as well as outreach and engagement of those hardest to reach and retain in care. People in recovery from mental illness (called peers or consumers) can be made a part of the public mental health system so they serve as navigators and trusted persons for those wary of mental health care. And no one stands a decent chance of getting better from a serious mental illness without safe and reliable housing with access to quality health and mental health services.

Indifference is cruel and costly. We can make a difference. People can have their rights and their lives — and their families, too. That’s what health care, including mental health care, is really all about.

The opinions expressed herein are solely my own as a psychiatrist and public health advocate.

I receive no support from any pharmaceutical or device company.

The study is the first of its kind aimed at understanding “adverse events” in hospitals — essentially, any medical care that causes harm to a patient, according to the Department of Health and Human Services’ Office of Inspector General.

Patients in the study, a nationally representative sample that focused on 780 Medicare patients discharged from hospitals in October 2008, suffered such problems as bed sores, infections and excessive bleeding from blood-thinning drugs, the report found. The federal Agency for Healthcare Research and Quality called the results “alarming.”

“Reducing the incidence of adverse events in hospitals is a critical component of efforts to improve patient safety and quality care” in the U.S., the inspector general wrote.

The findings “tell us exactly what some of us have been afraid of, that we have not made much progress,” said Arthur Levin, director of the independent Center for Medical Consumers and a member of an Institute of Medicine committee that wrote a landmark 1999 report on medical errors. “What more do we have to do to make sure that sick people can rest assured that they’re not going to be harmed by the care they’re getting?”

Among the findings in the report obtained by USA TODAY:

•Of the 780 cases, 12 patients died as a result of hospital care. Five were related to blood-thinning medication.

Two other medication-related deaths involved inadequate insulin management resulting in hypoglycemic coma and respiratory failure resulting from oversedation.

•About one in seven Medicare hospital patients — or about 134,000 of the estimated 1 million discharged in October 2008 — were harmed from medical care.

•Another one in seven experienced temporary harm because the problem was caught in time and reversed.

About 47 million Americans are enrolled in Medicare, a government health insurance program for people 65 and older and those of any age with kidney failure.

The adverse events found in the study weren’t necessarily due to medical mistakes, said Lee Adler, a University of Central Florida medical professor who was involved in the study. For example, he said, an allergic reaction to a penicillin injection is an adverse event, but it’s a medical error only if the patient’s allergy was known prior to the shot.

Among the problems identified in the report were Medicare patients who had excessive bleeding following surgery or a procedure. For example, one patient had excessive bleeding after his kidney dialysis needle was inadvertently removed, which resulted in circulatory shock and an emergency insertion of a tube to allow breathing.

When the tube was removed the next day, the patient inhaled foreign material into his lungs and needed lifesaving medical help, the report said.

Peter Pronovost of Johns Hopkins University, co-author of the book Safe Patients, Smart Hospitals, said medical mistakes are “an enormous public- health problem.”

“We spend two pennies trying to deliver safe health care for every dollar we spent trying to develop new genes and new drugs,” Pronovost said. “We have to invest in the science of health care delivery.”

While most patients prefer supportive measures that avoid a hospital death, U.S. patients received more chemotherapy. Ontario patients have more days in hospital, have more use of emergency rooms, and were much more likely to die in hospital.

An editorial about the study concludes the rates of inpatient deaths are too high in the U.S. and much too high in Ontario.

The study was done by the National Cancer Institute and specifically compared end-of-life care for lung cancer patients. The identified patients were 65 and older who died with non-small cell lung cancer.

The data came from The Ontario Cancer Registry and the U.S. Surveillance, Epidemiology, and End Results(SEER)-Medicare data bases for 1999-2003.

Patients in both countries used health-care services extensively, particularly in the last month of life. Ontario patients had hospital admissions and used emergency room services at rates that were statistically significantly greater than those of U.S. patients.

More than twice as many Ontario patients died in hospital (48.5 per cent of short-term survivors compared to 20.4 per cent in the U.S.). Yet, a majority of Ontario patients reported they would prefer to die at home.

In each of the last five months, chemotherapy rates were statistically significantly higher among U.S. patients than among the Ontario patients. It was noted that American doctors may have a more aggressive attitude toward treatment and that oncologists paid by Medicare can profit from some chemotherapy whereas oncologists in Ontario do not have a financial incentive to prescribe chemotherapy.

The authors of the study, including Joan L. Warren of the National Cancer Institute, felt the findings will inform health-care planners and policy makers about opportunities for change.

[Economist] MORE than a week after the earth convulsed beneath it, Haiti has still to plumb the depths of suffering and want. The numbers are still only more-or-less informed guesses, but their magnitude is grim: perhaps 200,000 killed, 250,000 more injured and some 3m in desperate need of help. The generosity of the world’s response has also been profound. Barack Obama led the way, dispatching 16,000 American troops and marines, but others, from Europe to Brazil, Cuba, China and Israel, responded too. Immediate promises of aid added up to around nearly $1 billion.

The urgent task is to connect this supply of help with the demand. That is proving extraordinarily hard (see article). Seven days after the earthquake, the United Nations had got food to only 200,000 people. Lessons from other disasters are not always relevant to Haiti. The Asian tsunami, for example, struck a ribbon of remote, mainly rural, areas. The governments of the affected nations could lead the relief effort. But Haiti’s institutions were weak even before the disaster. Because the quake devastated the capital, both the government and the UN, which has been trying to build a state in Haiti since 2004, were decapitated, losing buildings and essential staff. So did many NGOs. The president, René Préval, and his cabinet have been reduced to meeting in a police station.

Into that vacuum stepped the United States. Inevitably the dispatch of marines, Black Hawks and an aircraft-carrier looked to some like an invasion (after all, they have been there before). A brief caricature of great-power prickliness ensued as the Americans took charge of the airport and seemed to some others to give priority to their own flights. But by mid-week the airport was receiving three times as many flights as it did before the earthquake. The American forces are well-equipped for the vital task of setting up a supply chain for aid. That is what they are doing under a sensible division of labour eventually hammered out (the Brazilian-led UN peacekeeping force remains in charge of security, and the UN will co-ordinate the aid effort). Certainly most ordinary Haitians seemed pleased to see the Americans.

They are just desperate for water, food, fuel, medicines and shelter. Contrary to some reports, there were only isolated cases of looting and fighting. But delay and disarray has cost many lives. The longer it lasts, the more likely that desperation turns to violence. The UN called for more peacekeepers. Brazil offered 800; it may take weeks to muster the rest. If ever a situation cried out for the UN to have a standing army at its disposal, as The Economist has urged, this is it.

From relief to building a better country

Amid such chaos, it might seem premature to think about a long-term strategy for rebuilding Haiti. Actually, it is vital. Already Haitians’ resilient response to disaster is creating new facts on unstable ground: the spontaneous refugee camps around the capital will be hard to shift. Even before the earthquake Haiti was poor, environmentally degraded and aid-dependent and had few basic services. This means that “building back better” must be more than just a slogan. It also means that time is short before the world’s generosity turns to cynicism.

Fortunately there is a blueprint, drawn up by Haiti’s government and presented to donors last year. It calls for investment to be targeted on infrastructure, basic services and combating soil erosion to make farmers more productive and the country less vulnerable to hurricanes. The pressing question is who should do it and how. Haiti’s government is in no position to take charge, yet the country needs a strong government to put it to rights. Paul Collier, a development economist who worked on the plan, reckons that the answer is to set up a temporary development authority with wide powers to act.

Given the local vacuum of power, this is the best idea around. The authority should be set up under the auspices of the UN or of an ad hoc group (the United States, Canada, the European Union and Brazil, for example). It should be led by a suitable outsider (Bill Clinton, who is the UN’s special envoy for Haiti, would be ideal, perhaps to be followed by Brazil’s Lula after he steps down as president in a year’s time) and a prominent Haitian, such as the prime minister. To provide services, it should work with aid groups.

Some will object that this would undermine a democratically elected government. But there is not much left to undermine. Done well, it could create a state in Haiti able to do more than preside over chaos and corruption. Otherwise the suffering of the past ten days risks being repeated.

The federal agency also found that during this period:

• The proportion of people age 45 to 64 who incurred medical expenses did not change (about 89%), but average annual health care expenses for those with expenses increased from $3,849 (after adjusting for inflation) to $5,455.

• Prescribed medicines were a substantially higher proportion of total expenses in 2006 compared to 1996 (25% and 15%, respectively).

• The proportion of total expenses for hospital inpatient care decreased (from 36% to 26%).

• The average expense per service rendered also increased significantly (in 2006 dollars):

• Physician office visit $128 to $207
• Inpatient hospital day $3,005 to $3,491
• Emergency room visit $563 to $947
• Dental visit $195 to $265
• Prescription medicines $103 to $199

[Newswise] AHRQ, which is part of the U.S. Department of Health and Human Services, improves the quality, safety, efficiency, and effectiveness of health care for all Americans. The data in this AHRQ News and Numbers summary are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on the health services used by Americans, the frequency with which they are used, the cost of those services, and how they are paid. For more information, go to Trends in Health Care Expenditures for Adults Ages 45-64: 2006 versus 1996 at http://www.meps.ahrq.gov/mepsweb/data_files/publications/st255/stat255.pdf